PsychiatryTalk

Will You Have Enough Medication at the Time of a Disaster

Posted on October 3rd, 2017 by Dr. Blumenfield

Will you have Enough Medication at the Time of a Disaster?

Empty Medication Bottle

As we see people across the world struggle with unexpected disasters, we might wonder how prepared are we if one should strike where we live? There is a certain amount of preparation that we can do. We can try to live in a safe place. Some people build tornado cellars. One might have supplies to board up the windows. You might have a standby generator. There are now generators that work by solar energy. You can store extra food and water and keep a supply of fuel for your generator and for your car. It’s a good idea to have extra batteries, a hand-cranked flashlight and radio and alternate methods of communicating when the Internet and phone lines might be down. It’s also a good idea to have a first aid kit and supplies. But what about medications??

Would you have a sufficient amount of medication if your hometown were devastated by a catastrophic event and you are isolated for a period of time? What if the local pharmacies weren’t available to renew your medication or if the pharmacy supplies were cut off in an emergency? Suppose you couldn’t reach your doctor for a renewal of your meds? What if the computer systems were down and it cannot be verified that you had insurance for your medications?

Potential Serious Problems If You Run Out of Medication

Since this is a psychiatry blog, let’s start with some psychiatric medications. Certain tranquilizers such as the benzodiazepines can cause withdrawal symptoms if abruptly stopped. This includes Xanax, Ativan, Valium, Klonopin and other drugs especially if these medications are abruptly stopped and especially if you have been using them for a while. In addition, anxiety symptoms including PTSD that these medications may have been treating can be exacerbated at times of a disaster event. If a person who is taking major tranquilizers also known as anitpsychotic medicines such as Seroquel, Abilify, Risperdal, Zyprexa and many others or mood stabilizers such as Lithium, Depakote, Lamictal and many others if withdrawn may be expected to bring about a return of symptoms for which they were being prescribed. This could mean the development of psychotic symptoms with hallucinations, paranoia and delusions or the return of serious mood fluctuations including mania and depression. Similarly, a cessation of a needed antidepressant can cause return of the symptoms of depression and even suicidal ideation although it usually takes a couple of weeks for most of these types of medications to wear off.

Obviously there are similar major problems with a sudden cessation of other classes of drugs. Stopping anti-seizure medications obviously can lead to seizures. Cardiac medications are essential and their removal can lead to very serious problems as can medications for hypertension, diabetes, and various endocrine conditions. The abrupt cessation of medication being prescribed for pain most of which may be opiates can not only bring about the return of pain but some serious withdrawal symptoms. There are many other scenarios which can occur with the unavailability of various medications. And what about birth control pills?

Is it Possible to Have Back-up Medications?

There are also many scenarios where a person may have backup medication and also depending on the situations where that may not be the case. Doctors often prescribed a one-month supply of medications with a certain number of renewals. This might tide you over, but if you were a few days from a needing a renewal when the disaster event occurred, you would have a problem. Sometimes a 90-day supply may be given which probably would be okay unless you were coming near the end of your prescription at the time of the disaster event. Could you reach your doctor or some emergency coverage to get a renewal? Would there be an open pharmacy and will such a pharmacy be supplied with your medication? Also in an emergency or disastrous situation, power and Internet may be down and this could prevent your pharmacy from getting insurance authorization and approval. As you may know, without such approval, many medications can be extremely expensive.

Some people have told me that with each prescription they squirrel away a few pills so they can have a “stash” in case of an emergency. That approach may or may not work and keep in mind in such a situation the medication would most probably need to be rotated so the emergency pills were not outdated.

Could and would a doctor prescribe an extra supply of medication that would allow you to always rotate such pills and keep them current and therefore always have a supply in case of an emergency? Would this be judged as safe for a particular patient? For example, in case of potentially suicidal patients or in case of a situation where a particular medication can be abused, psychiatrists and the other physicians maybe reluctant to prescribe even a 90-day supply. As mentioned previously, medications can be very expensive and insurance companies are sometimes reluctant to authorize large amounts of medication. I also suspect that there may be regulations from state to state and in various different countries that would apply and which also may depend on the type of medication.

Proposed Project For Everyone

I would like to propose a project for the readers of this blog to undertake. Review your own medication. Check with your pharmacy and with your physician to determine if there is a method where you could always have at least a month supply of medication on hand in the event that you could not see your physician and that your pharmacy would not be available or able to fill your prescription at the time of an emergency or disaster. Also be sure to check any insurance coverage that you have whether or not that insurance company would cover the extra prescription and find out what the extra expense would be. Then, please report back to the readers of this blog and myself by putting a comment at the end of the blog. There is no need to publish your name. Perhaps it is time to advocate for some changes in regulations or perhaps we just need to remind people to be prepared.

Narcissism

Posted on July 16th, 2017 by Dr. Blumenfield

Narcissism

Screen Shot 2017-07-14 at 9.07.51 PMThe legend is that Narcissus was a handsome Greek youth who rejected the desperate advances of the nymph Echo. As a punishment, he was doomed to fall in love with his own reflection in a pool of water. Unable to consummate his love Narcissus was said to stare at his image in the pool hour after hour and finally pined away and changed into a flower that bears his name Narcissus.Screen Shot 2017-07-14 at 9.12.22 PM

Screen Shot 2017-07-14 at 9.10.21 PMIn 1911, Otto Rank, a prominent psychiatrist, spoke of narcissism as being related to vanity and self-admiration. A few years later, Sigmund Freud thought narcissism was not necessarily abnormal. He distinguished between primary narcissism with self-love which is linked to self-preservation and secondary narcissism where there becomes limited ability to love others and the problematic development of megalomania.

In the 1970’s, Otto Kernberg wrote extensively on this subject and felt that there was a group of people who have an unusual degree of self-reverence in their interactions with other people. He noted that Screen Shot 2017-07-14 at 9.16.57 PMin these individuals, there was a great need to be loved and admired by others and a curious apparent contradiction between a very inflated concept of themselves and an inordinate need for tribute from others. He believed that their emotional life is usually shallow and that they tend to experience little empathy for the feelings of others. Such people obtain very little enjoyment from life other than from the tributes they received from other people or from their own grandiose fantasies and they feel restless and bored when external glory wears off. Dr. Kernberg wrote about techniques for approaching such patients in psychotherapy.

 

Screen Shot 2017-07-15 at 10.54.33 AMThe latest version of the Diagnostic Criteria Manual (DSM-5) from the American Psychiatric Association stated that a Narcissistic Personality Disorder is a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and a lack of empathy beginning by early adulthood and present in a variety of contexts as indicated by five or more of the following.

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognize as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associated with, other special or high status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

It is possible and in fact is often the case that other mental health conditions may be simultaneously occurring along with a narcissistic personality. This might be depression or other mood conditions, or variations of psychosis, et cetera. The criteria stated above are provided for mental health professionals to make a psychiatric diagnosis. Different professionals may disagree whether an individual meets a particular criteria. Also, it should be obvious that only five criteria are necessary to make the diagnosis. Therefore, people with the same diagnosis might be quite different from each other. For example, an individual theoretically could be quite empathic and not be arrogant or have haughty behavior and still meet the criteria.

Any diagnosis should not be a derogatory value judgment of an individual. It is true that some of the above-criteria deal with being self-centered and not relating well to others which usually makes a person unlikeable. This is not always the case, sometimes a person with these characteristics may be quite charming and liked by others, as well as having other positive and endearing characteristics.

From my experience, it is true that people with narcissistic personality do not seek therapy as much as others do. But certainly that is not always the case. In fact, such a person may be particularly susceptible and even devastated by a “narcissistic injury” which would be circumstances which gives the person insight into their weakness, faults and vulnerabilities. Such a person may very well feel that he or she need help in dealing with these overwhelming feelings. Nevertheless, it still requires a set of specific circumstances for a person with narcissistic personality to decide to seek psychotherapy. Treatment of such of individual is often difficult and requires special techniques.

 

 

What Might Prevent Psychiatrists From Speaking in Public About Their Opinion of the Mental State of a Public Figure? The so called Goldwater Rule

Posted on July 7th, 2017 by Dr. Blumenfield

What Might Prevent Psychiatrists From Speaking in Public About Their Opinion of the Mental State of a Public Figure? The so called Goldwater Rule

In the United States the first amendment protects our right to free speech. Although I am not an attorney, I do believe that while you can’t be put in jail for expressing negative things about other people, there are laws that protect people from untrue damaging statements.. These laws provide recourse for people who believe that their careers reputations finances and/or health have been damaged by harmful statements. The Supreme Court has weighed in on this issue as recent as 1990 and the criteria involves whether the statements are true and the context in which they are made. Things get even more complicated when the object involves public officials and public figures who are in the public view because the law encourages free speech especially when it involves this category of people

What does all this have to do with psychiatry? In 1964 Barry Goldwater was running for President against the incumbent Lyndon Johnson. A magazine by the name of Fact published an article titled The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater . The magazine polled psychiatrists about American Senator Barry Goldwater and whether he was mentally fit to be President of the United States.Screen Shot 2017-07-07 at 11.24.30 PM In response to this question, 2,417 out of 12,356 responded. Of those, 657 said he was fit, 1,189 said he was not, and 571 said they didn’t know enough to answer the question. In response to the survey some of the comments that were made by the psychiatrists who responded were as follows (as reported in article in THE BLOG by Jonathan Moreno 8/26/16):

“The Presidency should not be used as a platform for proving one’s manhood . . .”

“Inwardly he is a frightened person who sees himself as weak and threatened by strong virile power around him . . .”

“Since his nomination I find myself increasingly thinking of the early 1930s . . .”

“Unconsciously he seems to want to destroy himself. He has a good start, for he has already destroyed the Republican party . . .”

Moreno in his article also made mention that in 1931 there was a debate at the annual American Psychiatric Association whether Abraham LincolnScreen Shot 2017-07-07 at 11.26.19 PM was a “manic schizoid personality whose depressive moods stopped short of mental illness.” The article went on to state that “analysis of the dead is not a legal violation, but nonetheless raises the question of fairness as the dead cannot defend themselves. He went on to say that to analyze a living person without data is not only bad practice, it also runs the risk of making the analyst look foolish if the individual later behaves in a way that was not predicted. The editor of that article about Goldwater was Ralph Ginzberg and he was sued for libel and lost the case and had to pay Goldwater $75,000 in damages which is approximately $579,000 in todays money value.

Several years later in 1973, the American Psychiatric Association issued the first addition of Principles of Medical Ethics which is still in effect as of 2017. I will list Section 7 , 1-5 but it is #3 that has informally known as the “Goldwater Rule” which is most relevant to the topic we are discussing. Screen Shot 2017-07-07 at 11.32.00 PM

Section 7

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

  1. Psychiatrists should foster the cooperation of those legitimately concerned with the medical, psychological, social, and legal aspects of mental health and illness. Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government. A psychiatrist should clarify whether he/ she speaks as an individual or as a representative of an organization. Furthermore, psychiatrists should avoid cloaking their public statements with the authority of the profession (e.g., “Psychiatrists know that”).
  1. Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness. Psychiatrists should always be mindful of their separate roles as dedicated citizens and as experts in psychological medicine.
  1. On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.
  1. The psychiatrist may permit his or her certification to be used for the involuntary treatment of any person only following his or her personal examination of that person. To do so, he or she must find that the person, because of mental illness, cannot form a judgment as to what is in his/ her own best interests and that, without such treatment, substantial impairment is likely to occur to the person or others.
  1. Psychiatrists shall not participate in torture.

There are very detailed procedures for filing an ethics complaint and how such a compliant will be evaluated on the local district branch level and then up to the national level which are spelled out in detail and include an appeals process. Potential sanctions to a member of the American Psychiatric Association who has been found to be in violation of one of the ethical rules are reprimand, suspension or expulsion from the national organization.

In a article in the Journal of American Academy of Psychiatry and the Law about one year ago Kroll and Puncey concluded that while some third party assessments are reckless but they do not negate legitimate reasons for providing thoughtful education to the public and voicing psychiatric concerns as acts of conscience. They concluded that the Goldwater Rule was an excessive organizational response to what was clearly an inflammatory and embarrassing moment for American psychiatry. A counter view with which I agree was expressed by  Paul Applebaum, Screen Shot 2017-07-07 at 11.44.22 PMM.D. , a past president of both  the American Psychiatric Association and the American Academy of Psychiatry and the Law in the current issue (2017) of the same journal. He said the following : “Weighing the real harms that can arise from psychiatrists’ comments on the diagnoses and personality traits of persons whom they have never examined against the likely inaccuracies and hence limited value of such endeavors to begin with, I am left with the conclusion that the Goldwater Rule remains a valuable component of the ethics of psychiatry. However, some modification of the Rule may be necessary, to indicate more clearly that it is not meant to cover analyses that are  intended to be shared with the public or works on deceased persons of historical interest.”

As far as I know there have been no sanctions by the APA regarding the Goldwater Rule thus far but this is still a topic which is being discussed both within and outside the psychiatric profession.

Any thoughts are welcome in the comments section below

 

What Should A Therapist Do in this Situation ?

Posted on January 27th, 2017 by Dr. Blumenfield

What should a therapist do under the following circumstances?

A 40 year old patient male) comes for initial consultation because he is unhappy with his life situation in regard to relationships and his career. There is no evidence of psychosis, severe depression or suicidal ideation. The patient has mild obsessive symptoms and there are various personality traits related to his family experiences. The patient is well motivated for psychotherapy and appears to have capacity for good insight.

The patient has occasional drink on weekends and no drug issues EXCEPT that he smokes marijuana most evenings and enjoys the experience. He also acknowledges that he does “ drive stoned” but he believes he is a good driver and has never had an accident. When this is explored further he acknowledges that he understands that his reaction time might be minutely slowed but he knows he is a better driver than most people. He expects to come for weekly psychotherapy and will drive about ½ hour to my office for an evening appointment. He also drives to work daily for about 45 minutes and sometimes will have joint before he drives home.  search

Questions:

 

1- Would you insist that you cannot treat him if he is engaging in dangerous behavior by driving stoned? Explain

2- Would you make this a high priority issues to work on in therapy whether the patient bring it up or not ? Explain

3-Would you deal with this issue as you would any other topic depending on his associations  and current conflicts as well as transference issues?

4- Would the answer to any of the above question be different if the patient were a moderate drinker and frequently drives while “buzzed“ or intoxicated?

( Please give your opinions in the comments section below )    imgres

My Memories of “9/11” on the 15th Anniversary of September 11, 2001

Posted on September 6th, 2016 by Dr. Blumenfield

... und explodiert nach dem Einschlag in das Gebäude. Beide Türme stürzten darauf zusammen. Kurze Zeit später prallte ein Flugzeug auf das US-Verteidigungsministerium in Washington. Die Flugzeuge waren zuvor gekapert worden. Vermutlich hat es hunderte Tote und Verletzte gegeben. (Foto: CNN)

My Memories of “9/11” on the 15th Anniversary of September 11, 2001

Introduction

If you have any memories of 15 years ago you certainly remember where you were, what you did and how you felt when terrorists took over two large airline planes filled with passengers and  crashed them into the World Trade Center in New York leading to the collapse one of towers and the death of thousands of people.

I would like to use this blog to recall my memories and thoughts about where I was, what I did and how I felt. As is often the case in recollecting traumatic events, I may not have every detail correct but this is how I recall things. I should state that I while I was in New York I was not near ground zero at the time and no one close to me was killed or injured.

As a psychiatrist, I previously had some experience in working with people who were traumatized. I was a consultant to a burn and trauma unit of a hospital and had written a book about this subject. A few years previously I was part of a team that studied the psychological effects of a major plane crash in Dallas and I had studied the psychological impact on emergency workers of doing their work, as well as the impact on members of the media who cover such events. I have had occasion to write and speak on related subjects before and after 9/11.

The Event

I was in my office at New York Medical College/Westchester Medical Center, which is a suburb of New York City. My secretary told me that she had heard that a plane had crashed into the World Trade Center. This immediately brought to my mind a childhood memory of when a small plane had crashed into the Empire State Building in New York City. My father was a New York City policeman at the time and called in the event to emergency services. He subsequently brought home, a small piece of twisted metal and wires that I was told were part of the plane. I was soon to learn that 9/11 was a much greater catastrophe than that event.

The nearest television to my office was on a closed psychiatric unit in the hospital not too far from where I was located. I made my way there and in the large day room all the patients and staff were watching a medium sized television. I quickly appreciated the magnitude of this event when shortly after I entered the room and focused on the TV, I saw pictures ofone of the tallest buildings in the world collapse on live TV. As I recall the experience, there was only a quiet murmuring or perhaps some groans coming from myself and the people viewing this together. I should point out that this was a closed psychiatric unit with acute severely mentally ill patients some of who would usually be in an agitated psychotic state, perhaps with hallucinations. I don’t remember any such manifestations being shown. It was almost as if many of the patients were jolted back to reality by this event. I didn’t study this phenomena but it reminds me of an experience that I had in my first year of psychiatric training. I was assigned to an inpatient unit at another psychiatric hospital in New York City when there occurred a highly unusual city wide black out of all power. As I recall, it was in the evening and the hospital basically went dark with no or very little emergency power for lights for several hours . I subsequently wrote one of my first papers examining the reactions of the various patients to this unusual circumstance.

While initially we had no idea of what was the cause of this plane crashing into the World Trade Center Building or that there were other planes involved. It was apparent that many people were killed although there was no indication initially that it would be in the thousands and that people were actually jumping out of windows to their death rather than being burned to death. As the magnitude became apparent, my natural instinct as was that of others, was to be concerned about my loved ones who worked in Manhattan. While I didn’t think that they would be at that location I made phone calls to assure that they all were safe. Many people did not receive good news as they checked with their family and friends. One man who I knew quite well, was director of clergy services at the hospital, lost his son at the World Trade Center. At that time I lived in one of many suburban communities outside of New York City where many people commuted to work by train. That evening there were many cars in the train station parking lot that were not picked up by people who had perished that day. Photographs of those cars that were not claimed by their owners that evening stands out in my memory.

The Aftermath

My wife who worked at a major hospital in Manhattan related how her hospital immediately had gone to it’s emergency plan waiting to receive large numbers of victims with injuries that were expected. Even the suburban hospitals such as mine went on to that mode where surgeons were called in and all personal were on standby expecting to deal with the overflow of casualties from this tragedy. But despite the approximately 3000 fatalities, I understand that there were very few injuries. The ash floating down on the city may have caused some minor medical problems.

Screen Shot 2016-09-05 at 11.01.40 PMIn the days and weeks following screen-shot-2016-09-10-at-12-08-59-amthis horrific event there was this very unusual phenomena of there being many posters on walls, trees, light poles etc not only downtown but in other parts of the city. The theme of these posters was looking for a lost relative. There would be a photograph and a brief description usually stating that the person worked in the World Trade Center and was missing. There would be a phone number to call if anyone knew about this missing person. The reality was that there were no missing people. The very few people who may have visited a medical facility were identified and all of these “ lost “ people had obviously died. However, understandably their loved ones in many cases could not initially accept what had happened and were trying to maintain hope . Over the ensuing days and weeks many of the posters remained in place but their makers had crossed out the word “ Missing” and there were words about how the poster was a memorial to them. Often there were flowers left next to them. I also recall passing a fire station from where many firemen had perished after they had entered the tower to save victims and had been inside when it collapsed. It was shrouded with black draping and an appropriate sign paying tribute to the lost heroes of that fire station.

I believe it was on Pier 92 in downtown that a massive social service outreach program was set up to assist the family and friends of people believed to be killed in the tragic event. There were places for people to register that they had lost a loved one. In many cases the remains of victims would not be found . There were psychological services offered to the distraught people many of whom were grieving lost loved ones.

I recall it was at this location that on the third or fourth day after 9/11 I was asked because of my previous experience in working with the media around traumatic events, to run a “debriefing group “ for members of the media who had been working day and night on this tragic news story. Many of them had spent hours interviewing grieving friends, relatives and the colleagues of the firemen who had died. They had seen and photographed the gruesome scenes of dead bodies and the partial remains. Some had photographed the falling bodies of the jumpers who chose to die this way rather than by fire. They spent hours talking on and off the air about all the details of news story, edited their material and in many cases went without or with very little sleep since the story broke. In the earlier days of “debriefing” victims of trauma the psychological approach had been to allow each person in the group to recount their experience. We had subsequently learned that such an approach often re-traumatized individuals who heard other people’s stories in the group. The approach now was more geared to explain to people about the symptoms which they might be having or might have in the near future and suggestions about how to deal with them as well as allowing them to ask any questions. We would also try to identify people having significant difficulties and offer them more individual help. In the course of running this group I mentioned how comforting members of the media particularly TV commentators might be to the public as they explain what is happening and try to keep the audience calm. Illustrating this point, I told them about a phone call I had just had with a family member who told me of a dream she had that Peter Jennings ( the ABC anchor) was talking and comforting her about the event. In the group I was speaking with was Peter Jenning’s TV producer who worked very closely with him and said she was sure that he would appreciate that story and she would tell it to him that evening. You can imagine how surprised my relative was when I called her and told her that Peter Jennings would soon know about her dream.

By coincidence I had been scheduled to do a Grand Rounds Presentation at a hospital in Manhattan not too far from ground zero 10 days after 9/11. It was pointed out to me that you could previously see the fallen tower from the room in which I was speaking. I don’t recall what the original topic was but we altered it to focus on that unforgettable event that had occurred in their backyard.

For many years   I have been a very small part of the large number of mental health professionals writing and teaching about how our profession can be helpful in dealing with mass traumatic events. As a therapist I realize that many people have their own individual traumatic experiences that impact them and often alter their lives. These personal traumatic events can be just as meaningful and life changing as a big event that affects large numbers of people .

While I was very fortunate not to have been  seriously traumatized by 9/11, but still the fear and worry that I had living through it along with millions of Americans  is obviously imprinted in my mind. Recounting it now in this blog relieves some of the pain  that is still associated with that memory.

 

Michael Blumenfield, M.D.

Mblumenfieldmd.com